Ban of user-fees almost doubled utilization of BPHS health facilities 

Developed in 2003 by the Afghan Ministry of Public Health (MoPH) with technical and advisory support of WHO, the Basic Package of Health Services (BPHS) ensures basic primary health care for the people of Afghanistan. It is complemented by the Essential Package of Hospital Services (EPHS) which provides secondary health care. Funding is provided by three major donors, that have divided the country’s provinces among them: World Bank, European Commission, and the United States Agency for International Development (USAID). 

USAID is providing its funding through the World Health Organization (WHO) under its health project called Performance-based Partnership Grant (PPG), which is supporting the implementation of the BPHS in thirteen provincesand of the EPHS in five provincial hospitals (Faizabad, Gardhez, Pakitika, Khost and Ghazni). The project provides health care services for over seven million people. The majority of them are receiving services in the form of BPHS delivered at facilities ranging from a basic health post to a district hospital. 

Altogether there are 26 contracts signed with 16 Non-Governmental Organizations (NGOs). The NGOs submit quarterly technical progress reports to the MoPH for analysis and feedback. WHO, in addition to its financial responsibility, reviews the technical reports and advises the MoPH and USAID on its findings. For the last quarter (April, May, June 2008) these reports show in general good progress in implementing the BPHS and EPHS. The quality of health care has improved, and the service delivery system has been expanded to underserved areas by establishing new health facilities.  

In detail, the review of last quarters technical reports shows that in the 13 provinces supported by USAID through WHO 382 health facilities including 17 District Hospitals (DH), 136 Comprehensive Health Centers (CHC), 205 Basic Health Centers (BHC), and 25 Sub Centers have been delivering services satisfactorily. Only a few health facilities reported stock-out of one or two drug items during the quarter. In addition, a total of 4503 basic health posts were functional during the past quarter, of which 86% were properly stocked with essential drugs. A common problem for all health facilities is the lack of professional female staff. Regular supervision of the Health Posts has been conducted by the NGOs during the last quarter. 8410 Community Health Workers (CHWs) have been supervised, which shows an increase compared to the previous quarter (7797 CHWs). 

A study that was carried out by John Hopkins University in 2004 showed that user fees do not comply with the MoPH mission of being sustainably equitable, quality and pro poor healthcare delivery. As a consequence, all user-fees were abolished by the MoPH in the beginning of the past quarter. This in addition to increasing accessibility due to establishment of new health facilities highly increased the utilization of services. It almost doubled which even caused some stock out of medicine. All the NGOs reported the service utilization by age and sex breakdown which is essential to ensure that all parts of the population are utilizing the provided services. 

All implementing NGOs reported good coordination at provincial and community level. Regular Provincial Public Health Coordination Committees (PPHCC) meetings were helt with other stakeholders, especially with the Provincial Public Health Directorate (PPHD) and the Provincial Public Health Officers (PPHOs) to brief them on the progress and to seek their support on addressing problems. On the community level regular meetings were organized by the NGOs with the communities’ health Shuras. Some communities made donations to their health facility, for example the construction of the facilities’ surrounding walls. 

Regarding the EPHS, the review of the NGOs technical reports showed that they have implemented Performance Quality Improvement (PQI) and Standard Based Management (SBM) as means of quality improvement, and maintained them in all five provincial hospitals. The utilization of services was high for all five provincial hospitals. They received their regular supply during the past quarter, and did not face any measurable stock out of essential drug. In-service training was conducted on a weekly basis in all of them. They organized and conducted monthly provincial hospital coordination meetings with stakeholders, as well as regular hospital community board meetings. 

However, security concerns and lack of professional female staff are still a big challenge towards the smooth implementation of the project. To increase the recruitment of female health workers’, some NGOs started to recruit female professional staff (doctors, midwives and nurses) from neighboring countries (Tajikistan and Uzbekistan). The deteriorating security affected both the demand and supply dimensions of the program. Security threats were a big concern for female health workers in some areas to attend their day-to-day activities. Monitoring and supervision are also seriously affected. Around 76% of all NGOs reported security incidences that more or less affected their services. Compared to the previous quarter when only 57% of the NGOs reported such incidents, it shows that the security situation has clearly worsened.